The fight over expanding Medicaid has gotten ugly, and the latest state to grab the spotlight is Mississippi, where a standoff in the legislature is pushing the state toward a cliff. Without a last-minute agreement, Medicaid may cease altogether there on July 1.

Most people think it won't come to that, but given the unpredictable nature of the fight over Obamacare, advocates and hospitals there are growing understandably concerned. Some 700,000 people are on the Medicaid rolls in Mississippi, and the program represents about 16 percent of the state’s hospital revenue.

Mississippi Gov. Phil Bryant (Jeffrey MacMillan/Capital Business) Mississippi Gov. Phil Bryant (R). (Jeffrey MacMillan/Capital Business)

"There’s a little edge of concern," said Gwen Combs, vice president for policy at the Mississippi Hospital Association, which represents most of the state's 119 hospitals. "But having said that, we are very hopeful that the parties are going to come together."

How did this happen? It is another strange reverberation from last year's Supreme Court ruling making the health law's Medicaid expansion optional for states, a decision that has thrown a number of state capitals into chaos this year and put Republican lawmakers in a particularly tight spot.

Mississippi is a fully Republican-controlled state, with the GOP controlling the House and Senate. Gov. Phil Bryant is not only a Republican, but a stalwart and vocal opponent of the health law.

State law requires that the legislature reauthorize Medicaid annually, and because it has a tax component, it needs the support of three-fifths of both chambers. This usually happens without fanfare. But Democrats in the House rejected the reauthorization bill. Their objection? Republicans will not permit a debate on expanding Medicaid under the health law, which would add 300,000 people to the Medicaid rolls. They have said they will not reauthorize the program without such a debate.

Everybody wants to keep Medicaid at least at current levels. But it has evolved into a game of chicken that led the legislature to adjourn in April without a resolution, and lawmakers still haven't come to a consensus. That has led to a flurry of finger-pointing.

"All the Republicans in the House voted four times to continue Medicaid as is," Nathan Wells, chief of staff for House Speaker Philip Gunn (R), said. "The Democrats were the ones who voted against it."

"They’re trying to say the Democrats killed Medicaid," said Rep. Steve Holland (D), a longtime advocate of Medicaid. "They know if there’s a debate about it they would lose because ...even a little pre-kindergarten child can understand the necessity of expanding Medicaid."

The governor has said that he hopes to hold a special session later this month to reauthorize Medicaid, and that he believes he has the power to run the program himself if the legislature does not, according to published reports.

If lawmakers are nervous about letting the program expire, they should be. Close to a decade ago, then-governor Haley Barbour backed a Medicaid reform bill that would have resulted in 65,000 elderly and disabled people being dropped from the rolls. It provoked a public outcry that damaged Barbour's approval ratings, said Roy Mitchell, executive director of the Mississippi Health Advocacy Program, which supports expanding Medicaid.

"The governor knows if they send out 700,000 letters to Medicaid recipients that they're going to lose their coverage there’s going to be a huge backlash," he said.

In an e-mail, a spokeswoman for the state's Medicaid division said the agency does not plan to send out any such letters because of the governor's plan to run it by executive order if necessary. Democrats say he isn't allowed to do that. Whatever happens, this game of chicken has put health care for hundreds of thousands of Mississippians at risk.